Breastfeeding Difficulties

breastfeeding difficulties

When Tongue Ties and Lip Ties Affect Feeding

A frenum is a normal part of oral anatomy but in some babies they attach higher than average with a shorter ligament that restricts oral muscle movements. The two most prominent frena in the mouth are under the upper lip and under the tongue. If these frena are restrictive in movement, the baby is referred to as being tongue tied or lip tied and can make nursing difficult for some mothers and infants. The indication for treatment is dependent on symptoms rather than anatomy present.

Symptoms for the baby may include:

  • Shallow attachment
  • Chomping down
  • Frequent feeds
  • Baby tiring and falling asleep during the feed
  • Clicking sounds
  • Lots of wind
  • Reflux symptoms
  • Milk spillage
  • Poor weight gain

Symptoms for the mother may include:

  • Compressed nipples
  • Maternal pain
  • Nipple trauma
  • Incomplete milk transfer by baby resulting in engorgement and/or mastitis
  • Low milk supply


An anterior tongue tie (or ankyloglossia) is when a membranous band of tissue (frenum) tethers the bottom of the tongue to the floor of the mouth. A posterior tongue tie or sub mucosal tongue tie refers to the ligament hidden under the mucosa that is not visible but can be palpated. This can restrict the movement of the tongue resulting in a decrease in the efficiency of nursing. Many of the babies we see have had the anterior membrane snipped but still continue to have difficulties. If the posterior tongue tie remains, it can inhibit the tongue from lifting high into the palate and forward to seal the lower lip whilst efficiently expressing and transferring the milk in a swallowing motion. A deep attachment with the tongue forward over the lower jaw’s bony ridge is also required to cushion and protect the mother’s nipple. Most babies should be able to empty the breast without discomfort to the mother in 10-15 minutes. If a baby is tongue tied, it can take much longer or they will tire easily having shorter and more frequent feeds.

Close up of baby's mouth with doctors hands    Close up of baby's mouth with doctors hands

Infant with an anterior tongue tie, posterior tongue tie and upper lip tie.

If the upper labial frenum is tight, the infant will not be able to flange their upper lip comfortably and the lips wide enough to get a deep attachment. This is commonly known as an upper lip tie. The baby’s opening is more an oval shape rather than round with the dry lip rather than moist mucosa contacting the areola or bottle teat. This results in an inadequate seal and can lead to air being swallowed and milk spilling out the sides. With a shallower attachment, a typical result is the baby becomes frustrated and tired, often chomping or biting the nipple leading to maternal trauma and pain.

Treating an infant is not a simple quick snip. The involvement of a qualified lactation consultant is the first step in helping to overcome nursing difficulties and to discuss the possible benefits of a frenectomy. At the lactation consultant’s recommendation, a consultation will then be booked for an examination/treatment with Dr Johnston. This ensures that the parents have enough information to make an informed decision to proceed to treatment. The indication for treatment in an infant is to improve nursing, both breast and bottle. It is an elective surgical procedure that should only be done if the parent feels the symptoms warrant it.

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